... copy and paste this text into an email, inserting your answers ... email to kristi@healingresonance4.me Healing Resonance, LLC with Kristi Borst 207 216 0473 Anticipated 1st Session Date: CLIENT INFORMATION Full Name: Tele # (indicate cell/home/office): Mailing Address: E-mail Address: Add to email list? YES(Y) NO(N) Male/Female: Date of Birth Age Who may Kristi thank (referral), or online search (state terms used if you remember)? CLIENT CARE Reason for today’s visit: When did you first notice the symptoms? Have you sought traditional medical care? Y N Concerns about? Alcohol Y N ; Drugs Y N; Tobacco Y N; Food Y N; Sleep Y N; Other ? Human Body Front/Sides/Back diagrams would appear here so you could communicate any areas of physical discomfort. Just write them in below, as applicable: P = Pain/Sensitivity N = Numbness S = Stress/Tension C = Constriction L = Lack of mobility O= Other DISCLAIMER: Healing Resonance llc with Kristi Borst should not be solely used to diagnose, treat, cure or prevent any disease or psychological disorder, and is not a substitute for licensed medical or psychological treatment. Kristi is an ordained minister, registered behavioral therapist & Reiki Master, certified in physio/spiritual massage. Her healing resonance (intuitive abilities & Source/Creator connection) and natural energy modalities balance mind/body/spirit/emotions to help reset the body’s natural healing intelligence. Client testimonials conveyed verbally or online do not constitute a warranty, guarantee or prediction of the outcome “It is likely that in your session(s), things blocking natural healing and/or wellbeing will rise to the surface for us to address together. I will teach you to work with your body and overcome the mind, yet YOU are a key player in your healing process!” Kristi Borst, PhD I AGREE (initial) Date: PLEASE NOTE: While spontaneous healings do occur, long-term traumas/dis-ease may require multiple sessions to hold long-term balance. “I recommend, but allow you to decide how many sessions you’ll have with me.” Kristi Borst, PhD I AGREE (initial) Date: FINANCIAL POLICY: Your appointment time has been removed from open booking and healing energy may begin coming to you in advance of your session. Please acknowledge that you understand (1) you are financially responsible for any session fees if not rescheduled or cancelled at least 24 hours’ in advance; (2) bank fees associated with returned checks will be your responsibility. I AGREE (initial) Date: YOUR PRIVACY is My Priority: Healing Resonance llc holds all your information in complete confidentiality. Kristi will not disclose any of your personal information without your written permission, unless required by law.